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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 107201156
Report Date: 11/15/2021
Date Signed: 11/15/2021 06:27:43 PM



STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710
This is an official report of an unannounced visit/investigation of a complaint received in our office on
06/14/2021 and conducted by Evaluator Malia Thao
PUBLIC
COMPLAINT CONTROL NUMBER: 24-AS-20210614082006
FACILITY NAME:FAIRWINDS - WOODWARD PARKFACILITY NUMBER:
107201156
ADMINISTRATOR:EDWARDS, DEANNEFACILITY TYPE:
740
ADDRESS:9525 N FT WASHINGTON RDTELEPHONE:
(559) 434-6444
CITY:FRESNOSTATE: CAZIP CODE:
93730
CAPACITY:270CENSUS: 211DATE:
11/15/2021
UNANNOUNCEDTIME BEGAN:
08:25 AM
MET WITH:Jessica Sommer, Operations Manager
Desiree Valero, Assistant Manager		TIME COMPLETED:
02:15 PM
ALLEGATION(S):
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Facility is overcharging resident.
INVESTIGATION FINDINGS:
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On 11/15/21 at 8:25 AM, Licensing Program Analyst (LPA) Malia Thao arrived unannounced to conduct a complaint inspection. LPA met with Operations Manager Jessica Sommer and Assistant Manager Desiree Valero.

During the course of the investigation, LPA conducted interviews, and reviewed records. Based on interviews, and record review, LPA found that the facility overcharged the resident $9408. R1 was charged for services that R1 did not agree to receiving and the facility could not produce documents to show R1 agreed to services. The above allegation is substantiated.

Deficiency is being cited based on LPA interviews, and record review in accordance with the California Code of Regulations, Title 22, see LIC9099D.

Exit interview conducted. A copy of this report will be emailed to Assistant Manager Desiree Valero with "Read receipt" to confirm receipt of this report.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Andy XiongTELEPHONE: (559) 650-7904
LICENSING EVALUATOR NAME: Malia ThaoTELEPHONE: (559) 650-7931
LICENSING EVALUATOR SIGNATURE:

DATE: 11/15/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/15/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710
This is an official report of an unannounced visit/investigation of a complaint received in our office on
06/14/2021 and conducted by Evaluator Malia Thao
PUBLIC
COMPLAINT CONTROL NUMBER: 24-AS-20210614082006

FACILITY NAME:FAIRWINDS - WOODWARD PARKFACILITY NUMBER:
107201156
ADMINISTRATOR:EDWARDS, DEANNEFACILITY TYPE:
740
ADDRESS:9525 N FT WASHINGTON RDTELEPHONE:
(559) 434-6444
CITY:FRESNOSTATE: CAZIP CODE:
93730
CAPACITY:270CENSUS: 211DATE:
11/15/2021
UNANNOUNCEDTIME BEGAN:
08:25 AM
MET WITH:Desiree Valero, Assistant ManagerTIME COMPLETED:
02:15 PM
ALLEGATION(S):
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3
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9
Illegal eviction.
INVESTIGATION FINDINGS:
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On 11/15/21 at 8:25AM, Licensing Program Analyst (LPA) Malia Thao arrived unannounced to conduct a complaint inspection. LPA met with Operations Manager Jessica Sommer and Assistant Manager Desiree Valero.

During the course of the investigation, LPA conducted interviews and reviewed records. Based on interviews, and records review, LPA found that R1 was issued an eviction notice, but afterwards the eviction notice was rescinded by the facility.

The above allegation is unsubstantiated.

Exit interview conducted. A copy of this report will be emailed to Assistant Manager Desiree Valero with read receipt to confirm receipt of this report.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Andy XiongTELEPHONE: (559) 650-7904
LICENSING EVALUATOR NAME: Malia ThaoTELEPHONE: (559) 650-7931
LICENSING EVALUATOR SIGNATURE:

DATE: 11/15/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/15/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 3
Control Number 24-AS-20210614082006
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: FAIRWINDS - WOODWARD PARK
FACILITY NUMBER: 107201156
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/15/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/16/2021
Section Cited
HSC
1569.657
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§1569.657 Rate increase due to change in level of resident care; notice (a) For any rate increase due to a change in the level of care of the resident, the licensee shall provide the resident and the resident’s representative, if any, written notice of the rate increase within two business days after initially providing services at the new level of care. The notice shall include a detailed explanation of the additional services to be provided at the new level of care and an accompanying itemization of the charges.
This requirement is not met as evidenced by:
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Operations Manager Jessica Sommer will reimburse R1 $9408 through crediting R1's rent account. Resident statement was provided as proof rent account was credited. POC cleared during inspection.
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Based on interviews and records review, LPA found that the facility overcharged the resident $9408. R1 was charged for services that R1 did not agree to receiving and the facility could not produce documents to show R1 agreed to services. This poses an immediate personal rights risk to residents in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Andy XiongTELEPHONE: (559) 650-7904
LICENSING EVALUATOR NAME: Malia ThaoTELEPHONE: (559) 650-7931
LICENSING EVALUATOR SIGNATURE:

DATE: 11/15/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/15/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 3